Couvelaire uterus is a symptom complex that occurs as a result of premature detachment of the normally located placenta and blood impregnation of the myometrium. The condition is manifested by acute abdominal pain and symptoms of massive internal bleeding, leading to intrauterine fetal death. It is diagnosed intraoperatively during an emergency caesarean section. Treatment consists in stopping bleeding by radical surgery – extirpation of the uterus with preservation of the ovaries and tubes. Methods of organ-preserving operations have been developed and applied.
Couvelaire uterus, or uteroplacental apoplexy, was first described in 1911 by the French gynecologist Alexandre Couvelaire. He characterized the apoplexy uterus as soaked in blood, cyanotic and incapable of contractions, with spot hemorrhages on the serous membrane. This condition is a rare complication of premature placental abruption, which is observed in 0.4-1.4% of all pregnancies. Of all the cases of detachment, 3.4-6.4% develop Couvelaire uterus. Maternal mortality from this complication reaches 5%. The fetus most often dies in utero.
The cause of the development of Couvelaire uterus is placental abruption and internal bleeding. Normally, the separation of the placenta from the decidual membrane occurs in the third period of labor. If the process is started during the gestation period, it threatens the development of acute fetal hypoxia, its death. The following factors predispose to detachment:
- Arterial hypertension. If hypertension existed at the time of conception, there is an incorrect formation of placental vessels. Fetoplacental insufficiency is observed during pregnancy, gestosis may develop. Frequent increase in blood pressure and severe gestosis can lead to detachment.
- Pathology of the uterus. Chronic inflammatory processes, complicated childbirth, operations and the consequences of abortions lead to micro-injuries and changes in the structure of the endometrium. Pregnant women have a violation of the formation of the placenta. When combined with additional factors, the probability of placental abruption increases.
- Coagulopathy. Diseases that increase the risk of thrombosis worsen during pregnancy. Microthrombs clog the vessels of the placenta, which causes its detachment and abdominal bleeding. Pathology of blood clotting and a tendency to microthrombosis is observed in autoimmune pathologies: systemic lupus erythematosus, antiphospholipid syndrome.
- Uterine fibroids. Nodes located in the thickness of the myometrium change the nature of blood flow, nutrition of the endometrium. The attachment of the chorion in the projection of the nodes increases the risk of circulatory disorders during late pregnancy, leads to fetoplacental insufficiency, fetal hypoxia.
- Extragenital diseases. The probability of violation of the formation of placental vessels increases with diabetes mellitus, hypothyroidism, anemia. Pathology may be associated with the effects of smoking, alcohol abuse in the early stages of pregnancy, when the chorion is formed.
The presence of predisposing factors does not always mean that placental abruption will occur. The producing causes are polyhydramnios, bearing twins, blunt abdominal trauma and premature birth.
The placenta is attached to the decidual lining of the uterus by anchor villi. Rupture of a vessel in them leads to bleeding and the formation of small hematomas. Gradually they merge into a large one and peel off the placenta from the muscle layer. If a rupture has occurred along the edge, external bleeding begins. Otherwise, a retroplastic hematoma is formed.
Continued bleeding leads to blood soaking of the placenta and myometrium. The uterine wall is overgrown, cracks appear. They receive blood, which can reach the serous cover, and after its rupture, exit into the parametrium and abdominal cavity. At the site of placental abruption, a large amount of thromboplastin is formed. It penetrates into the systemic bloodstream and leads to the development of DIC syndrome. The bleeding increases, causing severe hemorrhagic shock, and may result in the death of a woman.
Pathology is manifested by symptoms of placental abruption in severe form. Suddenly there is an acute abdominal pain, while there is no external bleeding or minor discharge is bothering. The localization of pain depends on the placenta attachment site. If the fetal place is located along the back wall, pain is given to the lower back and sacrum. Detachment of the placenta attached to the anterior wall causes acute pain below the navel and the formation of local swelling. Contractions may join. When the volume of the hematoma reaches 150 ml, hypertonus of the uterus occurs, the myometrium does not relax, the stomach becomes rocky to the touch.
The fetus is in a state of acute hypoxia, which is manifested at first by a sharp increase in its activity, followed by a complete lack of movement. The baby dies when 1/3 of the placenta area is detached. A woman with a loss of 300 ml of blood has hemodynamic disorders, symptoms of hemorrhagic shock are added. She feels weak, dizzy, tachycardia occurs, the skin turns pale and sweat appears. Breathing becomes rapid and shallow. Loss of consciousness may occur.
If you do not seek medical help in time, severe detachment leads to stillbirth. When the size of a retroplastic hematoma is 500 ml or more, the child’s heart tones cease to be heard. Massive blood loss becomes a trigger for hemorrhagic shock and DIC syndrome. In this condition, emergency surgical care and hospitalization in the obstetric department are necessary. Procrastination in the uterus of a Couvelaire leads to the death of a pregnant woman.
Couvelaire uterus is confirmed intraoperatively by caesarean section. The main diagnosis before surgery is aimed at establishing the fact of placental abruption. Clinical symptoms, anamnesis data, obstetric examination are taken into account, which is supplemented with instrumental diagnostics. Laboratory methods are necessary to clarify the severity of the condition.
- Examination on the chair. Spotting is noticeable in the genital tract, but they may be absent if there is a central detachment. The neck is closed, there are no signs of cervix maturation for a short period of time. The fetal bladder is intact, but tense, the water does not leak. The protruding part of the fetus above the entrance to the pelvis.
- External obstetric examination. Hypertonus of the uterus, its increase in size, sharp soreness is characteristic. If the placenta is located in front, the uterus may be deformed by local protrusion. In the case of antenatal death, there is no fetal movement, the heartbeat is not listened to with an obstetric stethoscope.
- HIC. According to cardiotocography, fetal hypoxia is diagnosed, the heartbeat is weak, bradycardia is characteristic. Fisher’s CTG score is less than 5-6 points. There is no movement of the fetus. In case of antenatal death on CTG, the heartbeat is not listened to.
- Ultrasound of the uterus. An echo-negative zone is determined between the placenta and the myometrium. It is possible to approximately calculate the area of the separated placenta. The fetal heartbeat persists until the moment of its death, but motor activity is reduced. The cervix is closed, of normal length.
In the presence of bloody discharge from the genital tract, diffdiagnosis is performed with bleeding associated with placenta previa. It is also necessary to differentiate the condition with rupture of the uterus by the scar. In the latter case, there is an indication in the anamnesis of a cesarean section or plastic surgery on the uterus.
The tactics of a gynecologist depends on the severity, the addition of complications in the form of DIC syndrome or hemorrhagic shock. Conservative therapy or wait-and-see tactics for severe detachment leading to the Couvelaire uterus are not used. The purpose of surgical intervention is to save the mother’s life, because the child often dies on the way to the hospital.
Before the operation, hemodynamic correction, blood loss compensation and treatment of DIC syndrome are performed. To do this, transfusion of freshly frozen plasma, cryoprecipitate, thromboconcentrate, introduction of recombinant factor VIIa, antifibrinolytics is carried out. Whole blood in DIC syndrome is prohibited for use. Intravenous infusion of colloidal and crystalloid solutions is continued after surgery, their ratio and volume are calculated individually. Narcotic analgesics are used for anesthesia in the first few days.
In the practice of most obstetric hospitals, premature detachment with the formation of the Couvelaire uterus is regarded as an indication for cesarean section. This is one of the few cases when the operation is performed with a dead fetus. In other situations, when a child dies in utero, childbirth leads through natural ways. Caesarean section is the initial stage of surgical treatment of the Couvelaire uterus. After fetal extraction and evaluation of the contractility of the uterus, a decision is made to extirpate the organ together with the neck with the preservation of appendages.
In the countries of Western Europe and the USA, the Couvelaire uterus is not considered an absolute indication for radical surgery. Organ-preserving techniques have been developed and successfully used. The main condition for their use is the absence of DIC syndrome and stable hemodynamic parameters in the mother. After fetal extraction, the following can be performed:
- B-linch suture. This is a compression seam that is applied through the uterine bottom, like the straps of a backpack. It leads to compression of the arquatic arteries – the largest vessels extending from the uterine artery. The effectiveness of the method is 90%.
- Omentouteropexy. The first stage of the operation involves ligation of the uterine arteries on three levels on both sides to stop bleeding. The second stage is the sewing of the omentum to the myometrium for its revascularization and the formation of vascular anastomoses.
- Embolization of uterine arteries. The operation is performed by a vascular surgeon. A gelatin sponge is passed through the femoral vein to the arteries feeding the uterus. It stops the bleeding, and after a month it completely resolves.
Organ-preserving operations allow women who, during their first pregnancy, were diagnosed with detachment complicated by the Couvelaire uterus, not to lose the chance to have children in the future. Statistics show that with the right tactics, a normal pregnancy is possible in patients after treatment.
Prognosis and prevention
The prognosis depends on the severity of the pregnant woman’s condition and the level of equipment of the medical institution. The question of the birth of a live fetus is not raised, in most cases, the baby dies with the Couvelaire uterus. Medical actions are aimed at preserving the life of the mother. With timely help, the availability of drugs for the correction of DIC syndrome, the chances increase. Therefore, the appearance of bloody discharge from the vagina during pregnancy is an indication for an emergency call to an obstetrician–gynecologist. Prevention consists in careful pre-gravidar preparation, correction of extragenital pathologies that can cause placentation disorders.